ISSUE BRIEF

State and Local Partnerships for Meeting the Healthcare Needs of Small and Often Remote Rural Communities

Thomas C. Ricketts III, MPH, PhD

merican healthcare has been described as a “non-system,” University and Bowman Gray) or whether to create a large A but there have been persistent efforts to coordinate and medical center by expanding the two-year medical school at the rationalize how we provide medical care in the United States. state university in Chapel Hill. Governor Melville Broughton These efforts have resulted in what may be called informal appointed a Medical Care Commission in 1944 to study the systems of care. A perfect example of one of those systems is in health and medical needs of the state. That commission recom- North Carolina, a system created for the people of the state’s mended the creation of a new, state-supported, four-year medical smaller and poorer communities, communities that are most school in Chapel Hill that would share space with the existing often rural and more often inhabited by racial and ethnic School of Public Health and occupy space adjacent to a new, minority citizens. comprehensive teaching hospital. After years of consideration, Almost all of North Carolina could have been called rural at the General Assembly supplied construction funds that were the end of World War II. The 1940 Census classified 72.7% of combined with money from the Hospital Planning and the state’s population as rural or living in communities with Construction Act of 1947, the Hill-Burton Act, to build fewer than 2,500 residents. A few cities—Charlotte, Durham, Memorial Hospital in Chapel Hill and to create the teaching hos- Greensboro, Asheville, Raleigh—had modestly large populations, pital. The Hill-Burton program also supported the construction but no city in the state had a population greater than 110,000. of many North Carolina hospitals and public health facilities in The state’s economy was strongly linked to agriculture, and the rural communities. prevailing perception of North Carolina was of a sleepy, rural, As late as the 1950s, healthcare services in rural North somewhat backward state. Carolina were considered inadequate. An unflattering review of World War II created an economic stimulus for the state the quality of general practice in the state was published in the when military installations were located in North Carolina— Journal of Medical Education in 1956.1 However, there were shipyards were established in Wilmington to build liberty examples of excellent medical care in some communities and ships, and facilities were developed to house prisoners of war in effective public health structures had long existed in others. the central and the mountain regions of the state. But the war The nation’s first local health department was established in left another legacy beyond economic benefit: the state had Guilford County in 1911. Robeson County set up the first experienced the highest medical rejection rate for its draftees of professionally managed rural health department in 1912 when any state in the Union. The causes for rejection were usually county commissioners appointed a full-time county health chronic problems related to nutrition and poor or unavailable director charged with the task of creating an administrative basic medical care and health advice. This embarrassing fact is unit of county government to ensure the health of the county’s often cited as the driver of the statewide “Good Health citizens. The state’s growing appropriations to the state Board Campaign” promoted in 1949 by prominent North Carolinians, of Health soon allowed other counties to organize their own including Kay Kyser, who recruited radio personalities and essentially independent public health units. Hollywood stars to help raise money and direct attention to the Walter Hines Page and the Country Life Commission, a healthcare needs of the state. That public effort had a significant national organization committed to “uplift rural folk,” helped to impact, but it built on prior efforts to expand health resources. bring the problem of hookworm disease in North Carolina and For years, politicians had been debating whether to assist one the rural south to the attention of the Rockefeller Sanitary or both of the private medical schools in the state (Duke Commission for the Eradication of Hookworm Disease, which in

Thomas C. Ricketts III, MPH, PhD, is a Deputy Director at the Cecil G. Sheps Center for Health Services Research and Professor of Health Policy and Administration in the School of Public Health at the University of North Carolina at Chapel Hill.He is also an Associate Editor of the North Carolina Medical Journal.He can be reached at [email protected] or CB# 7590,UNC-Chapel Hill,NC 27599-7590. Telephone: 919-966-7120.

NC Med J January/February 2006, Volume 67, Number 1 43 1909, began taking steps to eliminate this debilitating infection as Building AHEC: Bringing Clinical Training to one step toward improving the economy of the south. Because the Community state officials considered the direct involvement of the Rockefeller group to be too intrusive on a population distrustful of wealthy In 1965, Dr. Reece Berryhill, former dean of the UNC School northerners, the state Board of Health set up a cooperative Bureau of Medicine, became director of the new Division of Education for Hookworm Control to sponsor the campaign in North and Research in Community Medical Care, created jointly by the Carolina. The combined efforts eliminated the hookworm UNC Schools of Medicine and Public Health to work in local scourge and, in the process, created a lasting focus on public communities that were forming working relationships with health at the county level. Rutherford County physician, Dr. private practitioners. Dr. Berryhill was succeeded in 1967 by Benjamin Washburn, who had worked in Wilson County during Robert Smith, MD, a general practice physician formerly of Guys the hookworm campaign, began forming additional county Hospital in London. In 1967, the Division began an affiliation departments modeled on the Wilson experiment. with Moses Cone Hospital in Greensboro, with financial support A Division of Public Health in the two-year University of from Moses Cone Hospital, to give physicians from UNC- North Carolina (UNC) Medical School was created in 1936 with Chapel Hill another local practice option as part of their training funds from Title VI of the Social Security Act. That Division, in internal medicine and pediatrics. Later, through the Health under the leadership of Milton Rosenau, continued the tradition Councils of Eastern Appalachia, the Division received a grant of community-based programs and projects, and that orientation from the North Carolina Regional Medical Program in 1968 to became part of the tradition of the independent school of public support additional community-based training and to send clin- health that emerged in 1940. This commitment set the tone for ical specialists to smaller hospitals for teaching and consultation the next generation of public health and rural health leaders, assistance. In 1969, Glenn Wilson, the Vice President of Kaiser both academic- and practice-based, who assumed their positions Cleveland Health Foundation, was recruited to UNC-Chapel in the 1940s, 1950s, and 1960s and who viewed the role and Hill as Associate Dean for Community Health Sciences and as mission of state institutions as one of service outside their walls. the new Director of the Division of Education and Research in Milton Rosenau died unexpectedly in April 1946, soon after Community Medical Care. being elected President of the American Public Health The North Carolina General Assembly appropriated Association. The University’s President Frank Porter Graham, $395,000 for a community-based training program for physicians who was largely responsible for the service orientation of the at UNC in 1969 and again in 1971. These funds were used to University, followed the recommendation of the School of support fourth-year medical school clerkships in affiliated com- Public Health’s acting directors and named Edward McGavran munity hospitals in Wilmington, Charlotte, Raleigh, Rocky to become the new dean in April 1947. McGavran—a graduate Mount, and Tarboro. of Harvard Medical School, a former county health director, The Carnegie Commission on Higher Education, with director of a Kellogg Foundation public health training program, University of North Carolina President William Friday as a and a professor of Preventive Medicine at the University of member, issued its report Higher Education and the Nation’s Kansas—firmly fit the mold of the “outsiders” who came to Health in 1970. This report called for medical schools to devote North Carolina to encourage creativity in healthcare delivery more of their clinical training time to community settings using and public health. a new kind of entity, the Area Health Education Center. The An addition to the School of Public Health faculty ensured a United States Congress responded by authorizing the develop- focus on rural and community-based health services in the state. ment of a limited number of community-based health profes- In 1947, Cecil G. Sheps joined the faculty as an associate profes- sional educational partnerships under the Comprehensive sor of public health administration. Sheps, a native of Winnipeg, Health Manpower Training Act of 1971 (P.L. 92-157). That Canada, and his wife Mindel, a professor of biostatistics, had legislation, which surprisingly did not include the term “Area been involved in the development of the Saskatchewan health Health Education Center,” but used this term only in the con- insurance system that became the model for the universal, ference report that followed enactment, made available federal province-based system of healthcare financing in Canada. In a funds for demonstration projects that would link academic 1953 report to the Medical Society of North Carolina, Sheps health centers and community-based hospitals in networks maintained that a key ingredient in solving the state’s healthcare focused on the training of multiple health professions as well as delivery problems rested on “the development of a program of an the stimulation of professional continuing education of those extension of services from the University Health System to the already in practice. As this new legislation was enacted, Glenn state at large … in concert with other similar institutions of the Wilson at the UNC School of Medicine assembled an interdis- state so far as medical and nursing schools are concerned.” That ciplinary team to begin aggressive efforts to work out affiliation commitment was later to result in discussions that created the agreements with several additional hospitals and medical centers Area Health Education Centers (AHEC) concept. throughout the state for the purpose of applying to be designated as one of the first federally funded Area Health Education Centers Programs. The initial grant to the UNC School of Medicine to develop the AHEC Program in North Carolina was more than $8 million. The North Carolina AHEC Program

44 NC Med J January/February 2006, Volume 67, Number 1 would eventually involve collaborative relationships with the intended to examine was largely devoted to increasing access for four schools of medicine (UNC-Chapel Hill, Duke University, rural residents. As sites for its study of experimental comprehensive Bowman Gray School of Medicine of Wake Forest University,* health centers, the Research Center selected the rural parts of and East Carolina University’s Brody School of Medicine). Orange County and all of Caswell County, a 100% rural county. A key element of the AHEC structure was the creation of These areas formed the service area for a United States Office regional centers that were closer to rural communities throughout of Economic Opportunity (OEO) Neighborhood Health the state. There was one completely rural AHEC, termed “Area Center that used nurse practitioners. The Research Center soon L AHEC” after the multipurpose regional planning designation worked out cooperative research and technical assistance agree- for the counties surrounding Rocky Mount and Tarboro. The ments with other clinics being established in Walstonburg, decision to encourage distributed medical education recognized Tarboro, and Hot Springs—all of which were located in very the state’s demographics and gave the medical schools incentives rural sites in the eastern and western parts of the state. to work with essentially rural hospitals. That initial AHEC In 1970, three young United States Public Health Service focus on rural communities set a pattern for later development (USPHS) officers (James Bernstein, Ted Parrish, and Michael and orientation and closely followed the traditions of the Samuels) were selected as fellows in the USPHS Program in University and the state’s politics. Global Community Health and were given the opportunity to For the 1974/1976 biennium, the North Carolina General enroll in graduate programs in the UNC School of Public Assembly appropriated $23,500,000 for capital costs to build Health. Each of these young Public Health Service scholars regional AHEC centers, $4,548,720 for operating expenses, focused their work on problems related to rural primary care $1,125,000 for residency grants, and $250,000 for Community and the supply of rural healthcare professionals. All three men Practitioner Stipends. The General Assembly also set targets for were full-time employees of the United States Public Health training in the AHECs, committing the program to develop Service. All three men meshed well with the activities accompa- 300 new primary care residency positions by 1980. nying the development of the Health Services Research Center, Simultaneous with the establishment of the AHEC program, with Samuels concentrating on problems of professional the state also began funding family medicine training pro- recruitment, Parrish on community-based health education, grams. UNC established its Family Medicine Department in and Bernstein on the appropriate community structure for 1969 with Dr. Robert Smith as its first chairman, and the viable rural health services. Samuels graduated in 1975 and Bowman Gray School of Medicine in Winston-Salem opened went on to a career in the Public Health Service, during which its department in 1974. Duke University Medical Center he served as deputy administrator of the National Health added a division of family practice to its Department of Services Corps and the Health Services and Resources Community Medicine in 1972. The General Assembly has Administration and as deputy to the United States Surgeon continued its support of these programs with direct appropriations General. He later held faculty positions at the Universities of and capitated student and resident support. South Carolina and Kentucky. Parrish became active in local By 1975, the federal AHEC program had funded programs North Carolina health program development and is Chair of in 11 states, including North Carolina, where the concept had the Department of Health Education at North Carolina already received legislative, professional, and public acceptance. Central University. There is general consensus that the North Carolina Area James Bernstein took advantage of the commitment to rural Health Education Centers Program was, at its inception, and communities, which was the focus of the UNC-Chapel Hill remains today, the model for the nation, and that is due to the Health Services Research Center, where he was mentored by willingness of many partners to cooperate in its development Cecil G. Sheps, the Center’s director, and Glenn Wilson, the and operations. Associate Dean of the UNC School of Medicine. When James Holshouser became the first Republican governor of North North Carolina’s Health Services Research Carolina in the 20th century, he began exploring ways in which Center he could bring the influence of the governor’s office to bear on the extreme shortages of primary medical care in North Another key element of the rural policy structure fell into Carolina’s rural communities. He asked Dr. Cecil Sheps, then place with the founding of the Health Services Research Center the acting vice chancellor for health affairs at UNC as well as at the University of North Carolina at Chapel Hill in 1968. the director of the Health Services Research Center, to discuss The goal of the proposed center was to help develop more this matter with his colleagues and propose some concrete ways effective ways to “deliver personal health services in community in which the state might address these problems during his settings” by exploring “new roles for professionals” and productive four-year term of office. Sheps suggested to the new governor means to change organizational features of healthcare practice.2 the idea of community-based primary care clinics staffed by The Health Services Research Center fit snugly into the rural advanced practice nurses specially trained to meet the everyday health policy network because the community-based system it medical care needs of residents, who would be backed up in

* The Bowman Gray School of Medicine is now the Wake Forest University School of Medicine.

NC Med J January/February 2006, Volume 67, Number 1 45 their clinical work by local physicians. The governor asked the Office and its concepts and because the Office carefully Sheps to elaborate on this idea and present a detailed proposal avoided using its policy independence to compete for resources for how such an initiative might be taken. Dr. Sheps turned to directed to other agencies. The Office continued its independent Jim Bernstein to develop the formal proposal document. Once role during a reorganization of health agencies under the the governor studied the proposal, he concluded that it outlined administration of Hunt’s Republican successor, Governor a viable program, and he gave it his full support. He translated James Martin, during which time it was briefly aligned with the that support into an executive order that became part of his legisla- state’s health planning functions. It became the Office of Rural tive agenda. Subsequently, the proposal drew wide support from Health and Resource Development, placed administratively politicians of both parties, including the Democratic lieutenant within the Department of Human Resources, after Jim Hunt governor, James B. Hunt. Convinced that such a program would was elected for an historically unprecedented third four-year greatly benefit the state, the General Assembly created the Office term in 1992. The reorganization that resulted in the of Rural Health with an appropriation of $456,000 in 1973. Department of Health and Human Services (DHHS), under H. David Bruton, who served as Secretary of the newly named North Carolina Office of Rural Health Department. At that time, the Office was renamed the Office of Research, Demonstrations, and Rural Health Development A key element in the early success of the Office of Rural (ORDRHD, more often called the Office of Rural Health), to Health and its clinics was the support of the North Carolina emphasize its role in fostering innovative approaches to health- Medical Society for the use of nurse practitioners. Two prominent care delivery and financing. In 2000, when Michael Easley was physicians, Drs. Glen Pickard (of Chapel Hill) and Edward elected Governor, he appointed Carmen Hooker Odom as Beddingfield (of Wilson), convinced the Society to support a nurse DHHS Secretary, and she brought Bernstein into the position of practitioner practice act acceptable to the physician community. Assistant Secretary for Health. Following Bernstein’s retirement That support helped build the legal structure that allowed from state government in the fall of 2004, Torlen Wade became advanced practice nurses (called family nurse practitioners) to be Director of the Office, and it retains a key place in the structure trained, first at UNC-Chapel Hill and later at other institutions, of the Department. and the new clinics to open. Even with this broad backing, The accomplishments of the Office include the development gaining acceptance of the Office within state government of more than 80 rural health clinics; the placement and support remained a struggle. of more than 2,500 physicians, nurse practitioners, physician Professionals in the Department of Human Resources, assistants, and dentists; and the creation of the Community Care recently created during a general government reorganization to of North Carolina (CCNC, formerly Access II-III) networks that include the traditional public health functions as well as new and provide capitated care management for Medicaid eligibles. The old programs related to health services, did not believe the Office office also supports a Migrant Health Program that awards small would survive beyond the Holshouser Administration. After its grants yearly on a competitive basis to local health departments initial placement in the Governer’s Office, the legislature placed and non-profit agencies for primary care services to farmwork- the Office of Rural Health within the Division of Facility ers in high-need areas. This work is coordinated with the North Services, an agency previously responsible for administering the Carolina Association of Community Health Centers, which Hill-Burton Program and licensing hospitals. However, operates an active regional technical assistance system for the Governor Holshouser firmly insisted that the Office was Mid-Atlantic Region, as well as supporting the migrant health attached to the Division only for administrative purposes and centers in the state that any policy decisions were to involve consultation with the The Office of Rural Health may serve as the focus of policy Governor’s office. Prior to passage of the authorizing legislation relating to rural health issues, but it does not exercise formal and subsequent appropriations, the governor and the principal administrative responsibility for oversight or even coordination proponents of the program struck an agreement expressly of programs in other state agencies that serve rural communities delineating the direct route of accountability to the governor— or affect rural healthcare delivery. Instead, in part through support a surprising agreement since it bucked the current trend toward from private foundations, combined with the ability to create greater consolidation of government into cabinet departments. special programs from time-limited special appropriations, the This element of policy independence from other agencies in Office serves as a resource and brokering agency that stimulates government, consequently, provided the key to the success of coordination among program directors and exerts its capacity the Office and has remained one of its defining characteristics to add value to programs and projects with funding flexibility. to the present. Consequently, few programs or initiatives in primary or commu- The appropriation for the Office of Rural Health almost tripled nity-based healthcare delivery fail to receive some input from the in its second year to $1,200,000 and jumped to $1,611,000 in the Office, as much because of its experience in working with almost third year. Funding grew much more slowly afterward as the every aspect of the delivery system as for its policy role and its close Office gained recognition as a focused programmatic agency political ties to the General Assembly and the Governor’s Office. with a bounded set of goals. The Office established strong political stability in large part because Governor Hunt, elected to succeed Governor Holshouser, became a strong supporter of

46 NC Med J January/February 2006, Volume 67, Number 1 The North Carolina Foundation for Advanced operates in 99 counties as Community Care of North Carolina Health Programs (CCNC). The Foundation also supports and manages projects intended The North Carolina Foundation for Advanced Health to improve care for the uninsured poor, including a community- Programs, Inc., (NCFAHP) is a statewide non-profit organization based primary care program that has provided the impetus for charged with the mission of increasing the availability and the development of new start-up community health centers in affordability of healthcare for North Carolina residents. The Wilmington, Kinston, and Wilson County. The Foundation Foundation, established in 1982 on the recommendation of a also coordinated the “Covering Kids” demonstration to special legislative commission studying the issue of healthcare increase enrollment of children in Health Check/North costs in the state, serves as a catalyst for programs that improve Carolina Health Choice. Other projects included efforts to the quality of and access to healthcare while controlling costs. improve the management of health services, for example, sup- It works with business, medical, and civic leaders throughout porting the implementation of the Baby Love program in 22 North Carolina to explore solutions to healthcare problems and primary care centers to improve prenatal care; support of to develop specific approaches that meet community needs. pharmacy access projects, including the 340-B program in the In the early 1980s, the first major initiative by the Foundation state; and developing networks among rural hospitals to assist helped to expand the quality and number of competing alter- in compliance with quality standards. native health plans available to North Carolina residents in a The NCFAHP is also the recipient of other grants to sup- program to improve the healthcare marketplace. As part of that plement the work of the Community Care of North Carolina effort, the Foundation worked to bring health maintenance program in its primary care management systems in rural parts organizations (HMOs) to North Carolina for the first time. of the state. The NCFAHP is the coordinator for one of five The Foundation was also instrumental in establishing Preferred national demonstrations to improve the care of the elderly by Provider Organizations (PPOs) in the state and has encouraged improving working conditions for caregivers in the Better Jobs the formation of locally-formed alternative health plans. Better Care Program sponsored by the Robert Wood Johnson Through the hospital-based Rural Health Project, funded by Foundation. The Foundation also managed the National Program the Robert Wood Johnson Foundation from 1986-1992, the Office for the Practice Sights program. That work supported the Foundation helped to organize three hospital alliances, which development of model recruitment and retention systems in other assisted small rural hospitals in developing more cost-effective states using the successful methods and approaches of the methods of maintaining and expanding appropriate medical North Carolina Office of Rural Health. services. The primary objectives of this program were to improve the financial stability of participating hospitals The East Carolina University Medical School through the development of programs to improve market share, to enhance reimbursement options, and to increase the An important addition to the rural healthcare delivery structure quality of, access to, and cost-efficiency of health services for in the state was the East Carolina University’s Brody School of rural residents. As an outgrowth of this project, the Foundation Medicine, in Greenville, North Carolina. Predominately rural, has also developed a model to assist small rural hospitals in their with an economy based on tobacco-dominated agriculture, transition from acute care medical centers to primary care and eastern North Carolina has long projected an image as the specialty care providers. Our Community Hospital in Scotland state’s poorest region and has lagged behind the rest of the state Neck converted its 20-bed acute care unit into a 100-bed medical in industrial development. National commissions studying services center offering nursing home care and specialty care for methods to expand the supply of physicians had identified senior citizens as well as emergency care and augmented primary North Carolina as a potential candidate for a new medical care services for the general population. school. Politicians appreciated an opportunity to develop a stable The Foundation developed a program to improve the care economic engine for the east as well as to raise the prestige of of Medicaid recipients starting in 1986 with a single county the regional state university. However, the decision to create the demonstration program, the Wilson County Health Plan. That medical school was a contentious one. effort, jointly supported by the Kate B. Reynolds Charitable The battle to develop the East Carolina School of Medicine Trust promoted the concept of a “medical home” for Medicaid began in 1964 when Dr. Ernest Furguson, a general practitioner recipients in this largely rural county. From that demonstration, from Plymouth, North Carolina, and East Carolina College the Carolina ACCESS program evolved. This was a collaboration president Dr. Leo Jenkins agreed that East Carolina College with the North Carolina Division of Medical Assistance to (ECC), as it was then known, should build a medical school. implement a federal waiver to demonstrate regionally the effec- Dr. Jenkins asked local physician Dr. Ed Monroe and ECC tiveness of the “medical home” concept using a care manager Professor Robert Williams to conduct a needs assessment, supported with a per-enrollee fee. The program was successfully following which, Jenkins began an arduous campaign to locate implemented in 12 counties with the Foundation providing a medical school on his campus. leadership and management. With the approval of the General The initial proposal from the needs assessment called for Assembly, the program was transferred to the Division of Medical the creation of a two-year medical school that would send Assistance and implemented on a statewide basis and now students to the UNC School of Medicine for the remainder of

NC Med J January/February 2006, Volume 67, Number 1 47 their education, an idea strongly opposed by the three other The 1974 General Assembly appropriated funds to expand Schools of Medicine. Jenkins then went to the North Carolina the ECU school, adding a second year emphasizing family medi- General Assembly, which authorized and appropriated funds in cine and encouraging the recruitment of minorities. In November 1965 to plan a two-year medical school at ECC if accreditation 1974, President William Friday proposed to the UNC Board of could be obtained, ignoring a recommendation from a panel of Governors that the ECU School of Medicine become a full, consultants who preferred to expand the existing ECC allied four-year medical school, and the 1975 General Assembly health programs. When ECC requested, in 1967, that the appropriated funds to make his proposal a reality. Enrolling its General Assembly grant it independent status as East Carolina first class as four-year medical school in 1977, the school set as University (ECU), the legislature rejected that proposal and its central task the training of primary care doctors for rural and instead made it one of the constituent universities of the consoli- eastern areas of the state, with the intention of alleviating dated University of North Carolina system, but it also authorized apparent shortages of physicians. The school was renamed the the creation of a Health Sciences Institute at ECU (which Brody School of Medicine in 1999 in recognition of the Brody became the School of Allied Health and Social Professions.) family, prominent in business in the eastern part of the state. The need for more physicians in the state at that time was The ECU Brody School of Medicine has been active in the evident in statistics. North Carolina ranked 43rd of the 50 states training of primary care physicians with the support of the in the ratio of physicians to population and 46th in the ratio of Robert Wood Johnson Foundation’s Generalist Physician medical students to population. Mortality figures identified the Initiative, the development of rural community-based residency state as one of the least healthy regions in the nation. In 1969, sites, and participation in the Rural Scholars Program, where a Committee on Physician Shortage in Rural North Carolina medical students from ECU and UNC receive focused clinical appointed by the Legislative Research Commission acknowl- skills training in rural settings. edged the need for better access to medical care and as a solution, recommended the expansion of the UNC School of Medicine The North Carolina Student Rural Health from 75 to 200 graduates a year and the provision of subsidies to Coalition Duke University School of Medicine and the Wake Forest University School of Medicine to train North Carolina residents. The North Carolina Student Rural Health Coalition emerged Popular support for a medical school at ECU continued, as an outgrowth of the success of the Tennessee Student Health however, and in 1970, the General Assembly appropriated Coalition that began at Vanderbilt University in 1969 and funds to develop a two-year medical curriculum at ECU, developed into a family of effective student activist organizations, which then admitted 20 students to a one-year program. which included the Appalachian Student Health Coalition and Leaders in North Carolina’s other three medical schools had the West Tennessee Student Health Coalition. While he was a heavily invested in training specialists, and they argued that if a fourth-year medical student at Vanderbilt, Grady Stumbo, crisis in access to primary care existed in North Carolina, it directed a related, but more professionally-oriented project could best be addressed by training physician assistants and sponsored by the Student American Medical Association (SAMA) nurse practitioners. They also claimed that the problem was not to assist Appalachian communities. Those projects were the result a deficiency of medical students, but the lack of capacity for of a general sense of dissatisfaction among medical students with residency training. the relationship between organized medicine and formal medical In 1972, the UNC Board of Governors appointed a five- education and the needs of communities. The contrast between member committee headed by Lt. Governor Robert Jordan to the theoretical component of a medical education at Vanderbilt advise it on health manpower needs. The committee subsequently or the University of Tennessee and the reality of the lives led by recommended paying the Duke University and Wake Forest Appalachian residents in the late 1960s was too stark to be University Schools of Medicine a per-student stipend to train overlooked by concerned students in a period when social North Carolina medical students ($5,000 in 1975; $6,000 in activism was the prevailing ethic. Richard Couto describes the 1976), continuing to enroll 20 degree candidates in the one-year origins and development of those Tennessee projects in Streams ECU program, and commissioning a team of national consultants of Idealism,3 a title drawn from commentary by Robert Coles,4 for a feasibility study. who also figured in the development of social activism among The most significant body to study the issue of manpower healthcare professionals at the University of North Carolina and and the possible need for a second, publicly-supported medical Duke University and who remains active in both universities school was the so-called “Bennett Commission,” which ren- working with medical students and faculty. Donald Madison, a dered its report in September 1973. That report indicated that medical school faculty physician at UNC-Chapel Hill and one the proposal to build a four-year school of medicine in of the staff recruited by Cecil Sheps to begin the UNC-Chapel Greenville was “premature” and that the only hope of success Hill Health Services Research Center (now named for Sheps) was to expand the school of medicine at Chapel Hill. The played a substantial role in the development of the North North Carolina General Assembly, in the end, did not accept Carolina Rural Health Center movement. Not only did he take the key recommendation of this report and appropriated funds a lead role in writing the proposal to fund the Lincoln for the development of what is now the Brody School of Community Health Center in Durham and Durham County, Medicine at ECU. but he played an active role with the development of the Hot

48 NC Med J January/February 2006, Volume 67, Number 1 Springs Health Center in rural Madison County in the North to assist the community-based practices. Carolina mountains. In the mid-1970s, Madison was asked by The program has been able to leverage the original Kate B. the Robert Wood Johnson Foundation to lead the Rural Reynolds funds to a total of $12 million over the 15-year period. Practice Project, a national program in which multi-disciplinary That investment has allowed CCP-supported practitioners to teams of healthcare professionals and administrative personnel provide approximately $225 million in care to uninsured were assembled to begin primary care clinical practices in com- patients. The CPP is the only non-governmental program of its munities having severe access to care problems in several states.5,6 kind in the nation and other states and medical societies have In the early 1980s, students from a mix of health sciences looked to it as a model for their own efforts. schools organized the North Carolina Student Rural Health Coalition in the Durham-Chapel Hill area, with activity cen- The North Carolina Hospital Association tered at Duke University and UNC-Chapel Hill. The Coalition subsequently sponsored health fairs in rural communities, helped The North Carolina Hospital Association created the North place students and professionals in underserved towns and villages, Carolina Rural Center in 1996 to help its rural member hospitals supported public health awareness in rural communities, and cope with the special pressures they face. Initial support from agitated for more attentiveness to the rural healthcare and com- the Center came from the Association’s membership and a munity development needs of rural North Carolina. Eventually, grant from the Kate B. Reynolds Charitable Trust. Under the students from the ECU Brody School of Medicine and North leadership of Jeff Spade, the Center musters the resources of Carolina Central University combined to create the current current Association members, private consultants, state government structure of the coalition, which also includes students from the agencies, and university faculty to provide support and advice UNC-Chapel Hill School of Public Health and the UNC- to rural hospitals and communities. Its initial work focused on Chapel Hill and Duke University Schools of Nursing. the support of networks to bring resources to rural communities Students have been active in creating or supporting so-called through links between larger hospitals and smaller rural hospitals. “People’s Clinics.” Medical students from ECU, UNC, and The Rural Center sponsors an annual small and rural hospitals Duke University and nursing students from North Carolina conference that brings together individuals from all sectors of Central University offer free medical check-ups and other med- healthcare and community development. The support goes ical services in five community-managed clinics in eastern beyond networking to practical technical assistance in quality North Carolina: Fremont in Wayne County; Shiloh in Wake assurance and information technology, two areas that are at the County; Garysburg in Northampton County; Bloomer Hill, forefront of the Center’s agenda for the 21st century. which straddles the Nash-Edgecombe county lines; and Tillery in Halifax County. All five clinics are in rural, deprived, pre- The Duke Endowment dominately minority communities, with few, if any, medical care resources, very high infant mortality rates, and severe economic One of the largest private foundations in the United States, problems. with $2.5 billion in assets at the close of 2004, The Duke Endowment devotes part of its primary focus to the support of Community Practitioner Program hospitals and healthcare in North and South Carolina. It pro- vided over $39 million in health grants in 2004 and supported The North Carolina Medical Society Foundation developed almost every rural hospital in North Carolina with funds to the Community Practitioner Program in 1989 with initial support cover indigent care and special projects, including grants to coming from the Kate B. Reynolds Charitable Trust in the form renovate the obstetrics department in Ashe County in the rural of a $4.5 million grant. The program functions as a coordinating mountains and to develop an injury prevention center in center for the recruitment and support of physicians, physician Kinston in eastern North Carolina. In recent grants, The assistants, and family nurse practitioners who provide primary Endowment has emphasized children’s health, with multiple care in underserved areas in North Carolina. The funds go for grants to support school-based services. In 2005, its grants were loan repayment as well as for practice development. Practitioners focused on developing access to care for indigent populations receive support in return for five years of service in a qualified with an emphasis on prevention. The Endowment looks to fos- community, and they also agree to accept Medicaid and Medicare ter cooperation among agencies and organizations to leverage patients. To date, the Community Practitioner Program (CPP) funds for greater impact. For example, specific to rural health, has assisted 336 primary care physicians, physician assistants, and The Endowment, provided core funding for a family practice family nurse practitioners in 126 communities located in 76 residency program in Hendersonville, North Carolina. This economically distressed or medically underserved counties. In project involved the joint efforts of the Central and Mountain 2005, more than 400,000 patients were seen by CPP providers. AHECs, the North Carolina Medical Society, the state’s four Of the practitioners who were with the program for the five-year medical schools, other tertiary care hospitals in the region, and service period, 64% remain in the target communities; 73% the North Carolina Hospital Association. The Endowment is continue to practice in rural or economically distressed counties, targeting Health Information Technology in its 2006 health pro- and 85% remain in North Carolina. In 2006, the program will gram along with its traditional focus on access to care. For rural add a management support capacity, Project Sustain, to continue North Carolina, the Endowment supports projects in economic

NC Med J January/February 2006, Volume 67, Number 1 49 and social development through its “Program for the Rural the people of rural North Carolina receive the healthcare they Carolinas” that recognizes healthcare as an integral part of rural need. The number and range of programs described here points communities. to a single characteristic of the North Carolina approach to improving rural health: leaders in North Carolina healthcare The Kate B. Reynolds Charitable Trust and public policy have recognized that no one agency, organi- zation or institution could really improve access to care alone— The Kate B. Reynolds Charitable Trust was created in 1947 all of the fundamental elements of healthcare delivery had to be by the will of Mrs. William Neal Reynolds of Winston-Salem involved to truly have an impact. However, to make that happen, and is one of the largest foundations in North Carolina, with there needed to be some focus, some entity that, though it did assets of more than $500 million. Three-fourths of the Trust’s not “command and control,” helped various groups convene grants are designated for health-related programs and services and collaborate. That entity was the Office of Research, across North Carolina, and this amounted to $18.2 million in Demonstrations, and Rural Health Development which, in turn, grants in 2004. Many grants have helped support healthcare was supported by a network of connections and relationships innovation and service delivery in rural North Carolina as the that spanned government, the professions, and the institutions Trust sought to achieve its primary goal of increasing the avail- involved in healthcare delivery and finance. ability of health services to underserved groups. The Trust has The momentum for change was in place before the Office an explicit emphasis on funding rural areas. A sample of recent was founded—there were proposals for networks and changes grants illustrates this: funds to the Bertie County Rural Health in professional roles when the Office opened. But to make Association and the Tyrell County Rural Health Association for those things work in communities with the effective support of capital projects to support access-oriented facilities; to Blue agencies and institutions required some central organization to Ridge Hospital Systems to help improve access in a rural work out the details at the local level, negotiate with the powers mountain area; to the Pender County Health Department to that affected all aspects of healthcare delivery, and, in the end, expand dental hygiene services for low-income children. The allow the credit for the small and large victories to be shared. Trust works with other funders and agencies to coordinate its This comprehensive approach was not so much a formal work to enhance the impact of its giving; this is facilitated by process of consensus, but rather a shared recognition that all the participation on its advisory board of leaders in the North stakeholders were invited to join in the work and that these Carolina AHEC, the North Carolina Medical Society, North efforts ought to focus at the community level. While large Carolina Hospital Association, and regional civic leaders from bureaucracies and interest groups might be able to stand apart across the State. at the state level, it is in the local community that the dangers and negative effects of isolation and and separation are readily Bringing It All Together seen. NCMedJ

This brief review has only touched on some of the more prominent of the many people and programs that have helped

REFERENCES

1 Peterson OL, Andrews LP, Robert S, Spain RS, Greenberg BG. 4 Coles R. For American youth: Demands no other generation An analytical study of North Carolina general practice, 1953- has had to face. US News & World Report 1976 1954. J Med Educ 1956;31(12). September;81(10). 2 Miller CA. Proposal to the US Department of Health 5 Madison DL, Shenkin BN. Preparing to serve-NHSC Education and Welfare for a Health Services Research Center. scholarships and medical education. Public Health Reports Chapel Hill, NC. The University of North Carolina at Chapel 1980;95(1):3-8 Hill. March, 1968. 6 Madison DL, Shenkin BN. Leadership for Community 3 Couto R. Streams of Idealism and Health Care Innovation: An Responsive Practice: The Rural Practice Project. Chapel Hill, Assessment of Service-learning and Community Mobilization. NC, The University of North Carolina, 1987. New York: Teachers College Press, 1982.

50 NC Med J January/February 2006, Volume 67, Number 1